HomeMy WebLinkAboutWAT2023-00456 - WAT Application - 11/15/2021 MAIA fs' RFC
A1- �• � �
NOV I 6
E�v1RO Public } ~ Health s�5 w A/d ?a?1
H „ 6 Always working for a safer • healthier Mason County street
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 ) Belfair: (360)275-4467 ext 400 •:• Elma: (360)482-5269 ext 400
FAX (360)427-7787
Application for Determination of Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water system utilized.
3. Submit completed application, with attachments to the health department for review.
Part 1: Applicant/ Parcel Identification
Name on Applicant: FlCC e4 f.reF,..t Date: //4S4/
Mailing Address: 'X -n' /iil/ ?25 2L Phone:: 264 33 2 r—
Parcel Number:: 3 Z//A. - 7r- UCY,110
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ❑ Building permit
co nections) 0 Division of land:
L9."Individual water source (one connection), #of Parcels? SPL
C'YGVell 0 Boundary line adjustment
0 Spring/surface water 0 Other(explain)
0 Other(explain)
0 Replacement(please indicate name of water
If you have more than one residence connected system below if applicable-no signature
to this well, check the Public/Community Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory(WFI) Number:
(write"none"for two-party)
0 I am the manager of this water system. The water system has been approved for services.
There are presently connection(s) in use. This will be the connection.
0 I am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on this system (i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and willing to provide water to this (these) connection(s)without exceeding
the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Date
J:\EH Forms\Drinking Water Revised 12/1/15
Page I of:
This form may be scanned and available for public view on the Mason County Web site.
Individual Water Well
li Water well report(attached to application). Depth I� / ft.
Well capacity Test(attached to application) (Q gpm 7 0 gpd.
The well driller often performs well capacity tests at the time the well is constructed. Results from
these tests are noted on the water well report. Results from these tests will be accepted. If the water
well report cannot be located by the applicant or if the water well report does not have a capacity test,
a well capacity test, which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planninq 14K 15_16_22_
Water use or limitation recorded N/A Yes`(
Well Drilled Date 17% !ITS
Individual Spring/Surface Water
O WDOE permit(attach to application)
O Method of disinfection
O I have reason to believe that this water source can provide at least 800 gallons per day; and/or
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Date
Relationship to Applicant
• •
Part 3: Mason County Community Services Evaluation (staff use only)
Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
i Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
�R�evviiewer's Signatures:
Environ. Health: 2C�' r '' ' Date (13 I' (2i-
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
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•
DEPA�'MENT Or Notice of Intent No. W C .)-4 i 44 5 —
WATER WELL REPORT ECOLOGY Unique Ecology Well ID Tag No. 984 PI C.
Type of Work: S'atr of wat.hington
Site Well Name(if more than one well I:
tii
Cotstn.dxn
Water Right PermitCertiticate No.
C Decommission Use:
s:on original installation KOI No t ACC LI(A1C 0 eV C L d e tnT i 1 C
Proposed Use•. T Domestic ❑Industrial C Municipal Progeny Ow ncr Name / d
»Dcwatcring _Irrigation Test Well _Chico Z•1I E 5 u IMf-y/ -'CCd$ tL P _.
Well Street Addrxss
Method: 1N1 G So(x _ _
Construction Type: *Cable city 5llC /lot+ County
Dee well _Other Dior =Driven C Aired C Mud-Tool 3-L116 -75-p odyb —.
»Deepening C Other a Dug O Air- C Mud-Rotary Tax Parcel NO. 7
Dimensions: Diameterofboring in to. /tD it. Was a variance approved for this well? ❑Yes a No
Depth of comported well/47 it.
If yes.what was the variance for?
Cansuucti Details: Wall —
C'aciyg Liner D rcr Fro To Tlu' as Steel PVC Welded Thread /// ]ty�M'�—E\\'ivt
S�' irk t� in.A I •- A l 0 Locution(see instructions on page 21:
T r Ill= I C _ie. _ in. _ I - - I C S 4;4;of the 5.R.,•.Section__Township
21N.Range 31"/
! in. _ m. - ILi 1 -
I -_ _k io. CI - I - Latitude(Exanpk:47.1:345) l77-3a3 Z.
Longitude(Example:-120.1233�) +Z.3.0?fee Perforations: C Van eif} No Type of perforator used _
Drilkr's LnafConstrue.:on or Deenmrnissinn Procedure
Noof perforations__ J of pperforationsinby in. formation:Describe by color.character,size of material and.trix tare.and the kind alai
Perforatedred horn ft.to_tt.below ground surface �) nature of the material in each layer penetrated,with at least ore row-for each change of
K Pack cD Depth 5?11. information. Use additional sleets if ne.esWry —. •
Screens: j Yes C.No �'t� O T� Material From I To
Manufacturer's Name /'� ^D
Type. J1a I r .,�( ModelNo. P �Q/1
Diameter Cal in. Sktsize-tea' in from 42.4t.to 0+, 2 ��
D:amcur JJJ._ in. Sim owe__ in.from_ft to_ft- WeAus, ( " 1 e
Sand/Filter pack: Yes ,)(No Size of pack material h:.
c� 1 ,5� z i 4 / a
Materials placed torn,_ft.co IL '
Surface Seal:)(Yes To h. A
Material used in seal
I Did any strata eomain unusable water? »Yes To i
f, to ------
type of water' Depth •
_ — ..
Method of scallop.vans oft _
Pump:II P.I,. 'x Pump
in TYPc l✓�,
II P Wmp inakc depth: h. Designed now rue 1.1...+tin:
Water Levels: Wnd-wrtace ekvirinn.bevy moan.cu lete1��n
Suck-up of top of sing i (t.above wound surface
State water lest h.below top of well casing Date —71
1
Artesian n_lbs.persquareitch Date—____
water (cap.salse.etc.)
{ Wen Tn water u controlled by�— ---- ---.
Was Tech:
Was a pumping test performed? No ,-Yes ==> by whom? _.
1 told�_Kpm with_P.drawelowa after. hes. -----
Yield__man with_h.drawdown after_hrs. -"
Yield__gym with_fl.dmwdown after hrs.
Recovery data(Moe-zero when pump is tamed off-water lest mca..urd from well _—_
top to water lest( \\'ater Level Time water Level - ---" ._.
T Water level Timc
—_ _ --- -
Date of pu r WA
Bailer test ppm with 2,It.drawdown after_L has. - _!-
with stem set at__ft.for_,hrs. r Date
Air test__gpnt 9 A .•`�
Tempera floware lllN't Shlll Date Completed Dale f Z I I -
'I�CmpCrAlWt Ot water "F \Vas a chemical analysis teak' ^.Yes�`O
WELL CONSTRUCTION CERTIFICATION: I constructed and'or accept responsibilit)for construction of this well and its compliance with all Washington we
construction srandards.Materials used and the information reported above are true to my best knowledge and belief.
• fhillin C om n CIO/t S 1 t el
hiller C trainee C PE t Name Address (1O - n ' rlw
Si attire �I'C-1( W A - --
7City State Zip �t I t S VT 1�O o A
License No. Contractor's V (I 2 Li/
1F TRAINEE:S sor's icense No. Da.
Registration No
S rises Si attire —
ECY Persons with hewing loss can coil 71I for Washington Relay y Service.Perruon w with a speech disability can call 577-S3J-6341!I-4U7.6S71.
26276 Twelve
Trees Ln NW
Ste.0 SPECTRA Laboratories - Kitsap
Poulsbo,WA —_—
...Where experience awttrrs
9837000LIFORM BACTERIA ANALYSIS FORM
(360)779-5141 9-
Date Sample Collected Time Sample County
O / Coll ViAtiLso
Y (l v
Moat Day Year
Type of Water System(check only one box) `A ��
❑Group A ❑Group B (C4her J� ICJ
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): l71A)1/ (2
ID# oevn-tvt-e"
/
System Name: el
t &C� hi Woods
0odS rt
l L.+
Contact Person:
Day Phone: Cdl Phone:
Email: Eve.Phone:
Send results lo:(print NI vane,address and zip code or email above tor ekctronlc copy of results)
. Ot1/41 Y1?, 18 imyt-itvtait,,,QuaA_
SAMPLE INFORMATION
Sample collected by(name):
OCT 19 1U13
Specific location where sample collected: Special instructions or comments:
\N-)ft/t t( I 615 W. Alder Street
Type of Sample(check only one box)
1.0 Routine Distribution Sample(MP) 2.❑Repeat Sample(AlP)
Chlorinated:Yes ❑ No' (frO^distribution system after ur1 at routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total_Free
13.Ground Water Rule Source Sample ———
S
1 I Unsatisfactory routine collect date:
Chlorinated:Yes No
El Triggered (AP) Chlorine Residual:Total^Free_
0 Assessment(AR)
4.Surface or GWI Raw Source Water Sample(Enumeration) S I
❑ E.co/i 0 Fecal raved Yes- -hes_
4SamInformation Collected for Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Gaon Present and li<Satisractory
❑E.coff present ❑E.cof absent
Bacterial Density Results:Total Coliform mpnllDOml.E.coti - _mpni100m1.
Fecal Goff-am chu10Om1. HPC cfu/1ml.
Replacement Sample Required: ❑TNTC 0 Sample too rid
tE� SampleJ} Volume ❑Damaged Container 0
Daa t emit) (1-00 Lab Relerenoe Number o
Recei d Temp C: Method C 'SN9223B T-COUM'St9222D
-TNr report Y ford sooty to be use c'the earoo v cameo/to
�t d�ani10OOe'IM/O Ant uee npnigadKF)WedwMeyh
DlitT 0 3 2023 OtP 0 4 2023 :;esdrd copra•r Y�' 4 Ioone ee:, n
root*me Nair Oa'ends moss* .511'sd
Moo tle Neat wore*
DOM Lab-Sample
ff/r•� (j ,/ mew near rear on bee neat reed end M INTO IS
010• L mgybc bybo ie xrawy TK Iv r or'end not N'vaGd e oar*
ll rut aNal per ret.'mniar.maove+ ste<to:lik,TO 'r
DJrt Foxe Rn1J19(ea OG17)
2203829 MASON CO WA
10/27/2023 11.29 AM NOTCE
I
PCCURATE DEVELOPMENT #192098 Rec Fee $204 50 Pages 2
Return To IIllllI hil III III 111IIIIIIIINi 111111IItIIIJUI IIIIII IIIiIIiIIII I+IIIII
4c2e2/ £ 1-5E L52r7 .x -. \
g , 60K '7‘-
4 ir/j 4,49 GlPSz Q
Grantor(s): (1) . < �t a� , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) Z'( '5"-3d ,77✓ Se Sky / - -Z/—3
eviate orm:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: ( l_ . - 7 5-- D c 6' 4z d
TITLE NOTIFI►4: 10 F WATER RESOURCE INVENTORY AREA (WRIA)
I (We), the under ' ned n'3(s), hereby lace this notice on record that the described real
estate situated in ason unty, State of Washington is subject to water use restrictions and
conditions setl on State Senate Bill 6091 and Mason County Code 6.68. These
restriction nd c. 4 6 itions are based on location of property and/or Water Resource
Invento r WRIA.
W
a Annual Average Gallons Per Day: �S� gallons
ate, •on this 2sj day of l'ir , 20
ignature of Cr:, tor(s):
(1) L , (2)
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a Notary Public in and for the above named(County and State, do hereby
certify that on this 5 ' day of OCAo\y^ , 20. 3 ,
\\-moo( -\N5 •V,)o c ( personally appeared-befbcLne, who is known to be
signer of the above instrument, and acknowledged that = she) (th'eg) signed it
GIVEN under my hand and official seal the day and -; above written
No - Publi in and for the State of Washington,
My mission expires \L')— RA —
i SOT •
•
• ,1Leit •
\ ?• •• ,clipt •
{: If ' %1
cas)
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2203829 Page 2 of 2 10/27/2023 11:29:48 AM Mason County, WA